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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> f. Application h reby made to carry on busine s in the jurisdictional area of the San Joaguin Local Healtq District <br /> rBusiness Name-(DBA) AddressIaxlye <br /> ! _ J <br /> i Owner Address <br /> a <br /> 2 Firm Partners, Addresses and Tele one Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> i -i Contractor Licence No. <br /> LApplicants Name (Print) 42 1577 Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information CL.AcEF",,M'S Sr=V'C n F71�,iER SERVIC9 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 2u3 Sa. QiQ S•`.G !;iC^, iaiif. 95205 j <br /> For July 1, June 30, 19 Disposal Sites Dk Af <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> F No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> I 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT r ' <br /> Job Addr s/Locatio ' �nz f <br /> Owner <br /> Address <br /> I SEPTIC TANK 11 CESSPOOL XLEACHING FIELD SEEPAGE PIT C1 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY )(NEW ❑ REPAIR ❑ OTHER �[ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> l Plant Location ' <br /> l No. Units Served <br /> Plant Capacity 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ' ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I Hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ` ordinances, state Paws, and rules d regulations of the San Joaquin Lo I Health District. ��, r <br /> `! CIAIIiEfgCc S SF`=—•^ TR SERVICE <br /> r; li,� S. �''r';c <br /> APPLICANT'S SIGNATURE X ,t l ; Callf. <br /> \ Ph.1163-3209 Lac,#2671LA <br /> FOR DEPARTMENT USE ONLY <br /> 4 -Fee IS Due- El ANNUALLY I3 PER UNIT ❑ PER SITE 0EACH -❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE A L4 <br /> l LESS IT (+t IJ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ma/f, <br /> . <br /> Received by Date Receipt No. Permit No. Issuanc Date Mailed Delivered <br /> APPLICANT. RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br /> STOCKTON.CA 95201 <br />